30 January 2007

It all happened in Room 14, bed 2. The two of them came in a few hours apart and were like carbon copies of one another. Both middle-aged men in their late forties, somewhat overweight, blue-collar machinists. Both fully insured but had not seen a doctor in ages because "I just hate doctors." Both with large, dedicated, anxious families at their bedsides, certain that if Dad went in to see the doctor -- in the ER no less -- it had to be serious!

Both felt foolish for being there and apologized for "wasting my time."

I could have just photocopied the first medical record and used it for both of them.

Chest Pain- feels like gas bubbles in the chest, non-radiating- comes and goes for a week, worse today- not worse with exertion nor relieved by rest- not associated with nausea or shortness of breath

Past HistoryNon-smokerTold he had high blood pressure but was never treated.Thinks the last time it was checked, his cholesterol was "a little high"Father had early-onset heart problems

Both were symptom-free in the ER and had normal ECGs and a normal troponin.

I had identical, almost verbatim, conversations with both of them. "The good news is that the tests here look good and I can say that you are not having a heart attack." A quick look of relief flickered across both faces at this point as both wives exhaled deeply and said "Oh thank God." A pregnant pause follows. "The bad news is that the pain you describe is in some ways like heart pain, and you have risk factors for heart disease. I can't tell for sure whether there might be an impending heart attack, and we need to interpret these symptoms as a warning sign that further testing is needed. I want to admit you to the hospital for observation."

At this point, relieved and embarrassed, both wanted to just go home. Both tried to bargain -- promised to take meds and follow up with a doctor. Both wives demonstrated irritation and told their husbands not to be stupid. Both husbands irritably told their wives that "I knew it was nothing."

"Here's the thing, Mr _____," I respond, "I think the chance that this is your heart is low -- probably 5% or less. You like those odds, don't you?" Two nods with a subtle see, I told you so glance to to the wife. "But that's one in twenty," I continue, "and I am going to see twenty patients today. Do you want to be the one? Are you feelin' lucky, punk?" (The last bit delivered in my best Dirty Harry voice.) Both slumped back in defeat and their wives thanked me with immense satisfaction.

You never know. Both described symptoms much more suggestive of acid reflux than heart disease. I probably admit ten or twenty patients for observation for chest pain for each one that rules in. It's hard to do, because people hate to be admitted, the hospitalists don't want to do the admit, and it's a lot of work to admit someone. But you do it, because you don't want to fall into the "fallacy of knowing" and thinking you can predict in advance who will and who will not turn out to have "real disease." It is not very rewarding, and you feel like an idiot calling up the admitting doc twice in a row with a "low risk rule out that sounds more like GI disease than angina."

Patient number one was discharged from the hospital after eighteen hours of observation and a negative stress test. Patient number two had a triple bypass today, after ruling in and have three-vessel coronary artery disease showing up on angiogram.

My husband was having what he thought was heartburn, every time we took our daily walk. If a friend hadn't visited and suggested he should see the doctor (and then I had to drag him, practically) who knows what would have happened. Our doctor sent him to the heart specialist, who put him immediately into the hospital. He had a 4-way bypass... 4 days after our initial visit to our family doctor. And he was STILL in denial! Men.

Good eye, Rory. But it's just a stock ECG image I pulled off Google. Both patients did indeed have normal ECGs.

Though the guy that ruled in did so in the most amazing fashion, with an initial troponin of 0.02 (normal < 0.08), a four hour troponin of 0.55, and an 18-hour troponin of >100! That's what, a 4-log increase? Even more amazing was that on cath, though he had 3-vessel disease, there was no acute occlusion. The cardiologist said that they see that a lot with the transient-occlusive disease -- the vessel re-opens and there's a washout phenomenon in which the troponin skyrockets. The magnitude of the troponin increase does not necessarily correlate to the amount of necrosed myocardium. Seems counter-intuitive to me, but there you have it.

I have the verbatim same conversation 2-3 times a day.. I get so tired of it. I should just video tape it, document that they watched it explaining the facts and uncertainties of limited ER evaluations. When they decide to go home and die I can play the videotape to the jury that does explain that they might die and they chose the odds.

Can I just say thank you for practicing that way? We see too many cases where the ER doc only runs one set of enzymes and one EKG... Gives the patient the news that he is not having a heart attack and sends him home only to return the the ER in full code and eventually brain injury or death. I wish all ER docs practiced that way. Of course if they did, we would be out of business... Great Job Doc!!!

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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